Voluntary Statement

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First Name*

Last Name*

Address*

City*

State*

Zip Code*

Phone Number*

Birthday*

Birthday

Birthday

Occupation

Location where statement made*

Date and Time of statement*

Date and Time of statement

Date and Time of statement

Location of person at time of event*

Statement made by above named person*

Statement made by*

Witness

ARTICLE 2

OBSTRUCTION OF PUBLIC ADMINISTRATION AND RELATED OFFENSES

16 – 10 – 20 False statement, concealment of facts, fraudulent writings, etc., in matters within jurisdiction of state or political subdivisions.

A person who knowingly and willfully falsifies, conceals, or covers up by any trick scheme, or device a material fact; makes a false, fictitious, or fraudulent statement or representation; or makes or uses any false, writing or document, knowing the same to contain any false, fictitious, or fraudulent statement or entry, in any matter within the jurisdiction of any department or agency of state government or of the government of any county, city or other political subdivision of this state shall, upon conviction therefore, be punished by a fine of not more than $1,000.00 or by imprisonment for not less than one nor more than five years, or both. (Code 1933, SS 26-2408, enacted by GA L. 1976, p. 483, SS 1: GA L. 1979, p 1068 SS 1.)

I have either read or had read to me, the above section of the law concerning the concealment of facts, giving false information, or making a false or fictitious statement to the officers conducting this investigation.

I understand that a knowing or willful violation of this law can and may result in a legal action or prosecution being taken out against me and that I may either be jailed or fined or both according to the law.